Wyant, Nancy NEW YORK STATE DEPARTMENT OF HEALTH
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Vital Records Section Burial - Trans ermit
Name First A ( ,iddle Last _�/►e,1 C
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<` Date of DeathAge If Veteran of U.S. Armed Forces
(p /? 1/ War or Dates
j-= Plac- • Death Has•ital Institution or
11 Ci Town •r Village Street Address 2 3 a - / 7
a Manner of Death Natural Cause El Accident El Homicide 11 Suicide D Undetermined �Pending
Circumstances Investigation
W Medical Certifier Name 7Title
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Address P---73
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Death -rtificate Filed ( District umber Re - ter Nu ber
Cit , Town o Village J O/},)S a U n-es .
❑Burial Date Cemetery*Cremato ito/cY')
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Entombment /7 ' Ai tr " ' 6�
Address
remation Q v 19?e6-1-.___ l 'a UL-L- "-1-a kir �L
Date Place Removed /
Z Removal and/or Held
° ❑and/or Address
`~ Hold
ID
0 Date Point of
Ili El Transportation Shipment
ES by Common Destination
Carrier
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Q Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
,:: Name of Funeral Home .\I"\C_r V Alt;crA\ HO t`il t- C11 t Q
Address
1\ Lc.(y e. -- C i✓ast-s\L). 1 i KV 12-c6 C y
Name of Funeral Firm Making Disposition or to Whom
I Remains are Shipped, If Other than Above
2 Address
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a Permission is hereby grantedf� to dispose of the human remains described above as indicated.
Date Issued .r, -1_1 1, Registrar of Vital Statistics b
(signature)
District Number6(a5�� Place ZLN>N` , \ 14. (J1b1
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I certify that the remains of the decedent identified above were disposed of in accor ce with this permit on:
Z
III Date of Disposition 4/1(n Place of Disposition PaiV("Y'' C"NACtitti.
2 (address)
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CC (section) // (lot number) (grave number)
Name of Sexton or Person in Charge of Premises i(r., t� StA4t
.Zr (pease print)
Signature ,Afi Title 0414frig.-
1 (over)
DOH-1555 (02/2004)